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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
Medicaid Forms Sorted by Form Type

Last Revised: July 14, 2008

This list contains all Medicaid forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language
Paper Medicaid / BadgerCare Certification form F-10110 1/1/1999 English
PDF - Fillable Administrative Disqualification Hearing Notice F-16038 1/1/2008 English
PDF - Fillable Agency Response to the State Quality Assurance (QA) Medicaid Finding F-10172 4/1/2007 English
PDF - Fillable BadgerCare Plus / Medicaid Health Insurance Information F-10115 2/1/2008 English
PDF - Fillable Community Spouse Asset Share Notice F-10096 4/1/2008 English
PDF - Fillable Estate Recovery Program (ERP) Disclosure F-13039 7/1/2005 English
PDF - Fillable Good Faith Medicaid / BadgerCare Plus Certification F-10111 2/1/2008 English
PDF - Fillable Income Maintenance Quality Assurance (IMQA) Web Request F-16083 4/1/2005 English
PDF - Fillable Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant F-10142 10/1/2005 English
PDF - Fillable Medicaid - Disability Application F-10112 10/1/2007 English
PDF - Fillable Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S 3/1/2005 Spanish
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 2/1/2008 English
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H 2/1/2008 Hmong
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) F-10126S 2/1/2008 Spanish
PDF - Fillable Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 2/1/2008 English
PDF - Fillable Medicaid / BadgerCare Plus Overpayment Notice F-10093 2/1/2008 English
PDF - Fillable Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse F-10095 1/1/2008 English
PDF - Fillable Medicaid Change Report F-10137 1/1/2008 English
PDF - Fillable Medicaid Change Report - Hmong F-10137H 2/1/2008 Hmong
PDF - Fillable Medicaid Change Report - Russian F-10137R 2/1/2008 Russian
PDF - Fillable Medicaid Change Report - Spanish F-10137S 2/1/2008 Spanish
PDF - Fillable Medicaid Disability Redetermination Report F-10114 1/1/2004 English
PDF - Fillable Medicaid Health Insurance Information - Spanish F-10115S 12/1/2004 Spanish
PDF - Fillable Medicaid Income Allocation Notice F-10097 2/1/2008 English
PDF - Fillable Medicaid Manual Notice for Cost of Care Contribution F-10108 4/1/2008 English
PDF - Fillable Medicaid Member Asset Allocation Notice F-10098 1/1/2008 English
PDF - Fillable Medicaid Presumptive Disability F-10130 4/1/2008 English
PDF - Fillable Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  F-10127 3/1/2008 English
PDF - Fillable Medicaid Purchase Plan (MAPP) Independence Account Registration F-10121 2/1/2008 English
PDF - Fillable Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  F-13024 12/1/2001 English
PDF - Fillable Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  F-13023 12/1/2001 English
PDF - Fillable Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice F-10106 1/1/2008 English
PDF - Fillable Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice F-10107 1/1/2008 English
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong F-10129H 1/1/2003 Hmong
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian F-10129R 1/1/2003 Russian
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S 1/1/2003 Spanish
PDF - Fillable Negative Notice F-16001 1/1/2008 English
PDF - Fillable Negative Notice - Spanish F-16001S 4/1/2006 Spanish
PDF - Fillable Notice of Program Violation F-16014 4/1/2005 English
PDF - Fillable Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility F-10099 2/1/2008 English
PDF - Fillable Positive Notice F-16015 1/1/2008 English
PDF - Fillable Positive Notice - Spanish F-16015S 4/1/2006 Spanish
PDF - Fillable Self-Employment Income Worksheet - Corporation F-16034 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Partnership F-16036 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Subchapter S Corporation F-16035 3/1/2008 English
PDF - Fillable Social Security Number Referral F-16022 1/1/2008 English
PDF - Fillable Statement of Citizenship and / or Identity for Special Populations F-10161 2/1/2008 English
PDF - Fillable Statement of Identity for Children Under 18 Years of Age F-10154 2/1/2008 English
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Hmong) F-10154H 2/1/2008 Hmong
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Russian) F-10154R 2/1/2008 Russian
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Spanish) F-10154S 2/1/2008 Spanish
PDF - Fillable Student Aid and Expense Worksheet F-16031 12/1/2001 English
PDF - Fillable Student Financial Report F-16021 4/1/2008 English
PDF - Fillable Verification of Veterans Benefits F-10162 2/1/2008 English
PDF - Fillable Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 2/1/2008 English
PDF - Fillable Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 3/1/2008 English
PDF - Fillable Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet F-10101 8/1/2008 English
PDF - Fillable Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) F-10101H 8/1/2007 Hmong
PDF - Fillable Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) F-10101R 8/1/2007 Russian
PDF - Fillable Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) F-10101S 8/1/2007 Spanish
PDF - Fillable Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 2/1/2008 English
PDF - Fillable Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (Spanish) F-10140S 2/1/2008 Spanish
PDF - Print Authorization to Disclose Information to Disability Determination Bureau (DDB) F-14014 7/1/2008 English
PDF - Print Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) (Spanish) F-14014AS 7/1/2008 Spanish
PDF - Print Estate Recovery Program (ERP) Disclosure Instructions F-13039A 7/1/2005 English
PDF - Print Good Faith Medicaid Certification Instructions F-10111A 8/1/2003 English
PDF - Print Information for Medicaid Disability Applicants F-10113 2/1/2008 English
PDF - Print Information for Medicaid Disability Applicants (Spanish) F-10113S 2/1/2008 Spanish
PDF - Print Local Agency Customer Feedback F-16104 8/1/2007 English
PDF - Print Medicaid Manual Notice for Cost of Care Contribution Instructions F-10108A 4/1/2008 English
PDF - Print Medicaid Purchase Plan (MAPP) Member / Premium Information F-10122 3/1/2008 English
PDF - Print Medicaid Remaining Deductible Update F-10109 11/1/2003 English
PDF - Print Statement of Identity for Persons in Institutional Care Facilities F-10175 2/1/2008 English
PDF - Print Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A 3/1/2008 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 8/1/2007 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S 5/1/2007 Spanish
Word - Fillable Employer Verification of Health Insurance F-10155 4/1/2008 English
Word - Fillable Employment Verification of Earnings F-10146 12/1/2007 English
Word - Fillable Life Insurance Inquiry F-10144 1/1/2005 English